SHAHC adapts the Pathways Model to ten counties in New Mexico and uses the established database to track progress, outcomes, and ensures long-term, sustainable success. The CBPR model is used to ensure collaborator feedback is utilized for county/region-specific qualify improvements on a rolling basis. SHAHC will connect eligible participants with CHWs who will assist them in gaining access to necessary resources, ensuring greater efficacy and disbursement of funds to shore up the community against housing instability.

• Aim One: Increase levels of long-term housing stability.
• Aim Two: Increase knowledge the utilization of resources.
• Aim Three: Increase community involvement.

Through a network of approximately 44 community health navigators (CHWs) employed by the 17 partner organizations contracted by our office, Pathways focuses its efforts on identifying and working with the most difficult to reach residents of Bernalillo County, to connect them with a wide variety of health and social services. This program follows an outcomes-based step-by-step national model (Pathways). Our office serves as the “hub” and provides ongoing training and support of the CHWs, collects and analyzes data to ensure that participants of the program are having many of their needs met, and addresses system problems that inhibit access to these important services.

• Aims to decrease hardships related to unmet social needs such as housing stability, food insecurity, access to utilities, lack of transportation, and interpersonal safety
  Program initially designed to address the opioid epidemic in Bernalillo County, but is not limited to only opioid addictions
• Criteria
  • Co-occurring disorders with a primary diagnosis of substance abuse in addition to
    2 ER visits in the past 12 months and
  • 1 incarceration in the past 24 months (not limited to Bernalillo County boundaries)
• Three year grant with the City of Albuquerque
• ICM Sub-contracts with 3 partner community agencies and maintains 4 ICMs/CHWs through the CHWI office for a total of 7 ICMs.  
• ICMs typically carry an average case load of 12-15 high-needs clients, providing long-term services as needed

• Provide housing vouchers for qualifying recently incarcerated individuals through newly funded (for CHWI) Bernalillo County grant 
• Provide intensive case management to 600+ clients (focused on high needs clients) currently waiting for housing vouchers, with aim to reduce number of clients lost while on wait list; will actively seek and connect to housing once vouchers become available to our program
• Four in-house Community Health Workers will carry a 15-20 client caseload with 2 in-person visits per month

• Salud es Riqueza - Salud es Riqueza (Health is Wealth) is a diabetes prevention training program for Community Health Workers (CHWs) that work in New Mexico - providing them with a comprehensive toolkit to aide in the care of their adult clients. This training initiative is a collaboration with Project ECHO and will train a total of 70 - 80 CHWs in 2023-2024.
• Health Equity - The UNM-CHWI Health Equity Team works collaboratively with the New Mexico Department of Health, including the Office of Community Health Workers, and multiple partner organizations throughout the state to provide access to and promote understanding of COVID-19 vaccines and holistic health. Partnering with statewide community-based organizations helps ensure that our efforts are community driven and center the CHWs/CHRs working in their communities to address health inequities. We work together to share accurate information and resources with people that live in areas with high social vulnerability and/or who are members of communities that have been most affected by historic health inequities and the COVID-19 pandemic. Our collaborative initiative allows local organizations, tribal Community Health Representatives, Promotores de Salud, and Community Health Workers to lead the way, helping to ensure that people get the information they need as we aim to empower and protect the communities of New Mexico. Ended 6/30/24
• Tiny Home Village (THV) - The THV is the first of its kind in NM, a transitional housing program. The village is located at 105 Texas ST SE in the heart of SE Albuquerque and has 30 tiny homes of approximately 120 sq ft.  CHWI works with Bernalillo county who owns and operates  the village in addition to providing 24/7 operation staffing. CHWI is proud to provide onsite case management via 2 full time lead chws and 1 full time social worker/counselor. Our job is to help heal and house folks as they transition from THV. Ended 6/30/24
• Increasing EITC in New Mexico, also known as the Earned Income Tax Credit program, is a federally funded grant by the Office for Minority Health. The goal of this grant is to determine if implementation of Earned Income Tax Credit (EITC) outreach and education activities in communities at higher risk for ACEs can result in (1) increased EITC receipt and (2) changes in risk and/or protective factors for ACEs.  This grant also has a research component to it, which uses pre and post tax assistance surveys to measure outcomes of the study. The EITC, a benefit for working people with low to moderate income, has been shown to reduce child maltreatment and foster positive health outcomes and reduced health care costs by reducing poverty and enhancing economic stability of low-income, working families. The EITC team collaborates with Community Health Workers from UNM and First Choice clinics, as well as 17 partner organizations, located in designated "opportunity zones" and address social determinants of health. These CHWs have been trained by our team to screen clients and patients for EITC and refer those who are eligible, to our program for free income tax preparation. While working with our clients, we provide education on financial literacy and address any ACEs the client may be going through. Ended 9/30/23
• Emergency Rental Assistance Program (ERAP) - The University of New Mexico Health Sciences Center (UNM HSC) Office for Community Health (OCH) Community Health Workers Initiatives (CHWI) Pathways Program provides education and support to marginalized communities in Albuquerque on the Emergency Rental Assistance Program (ERAP). The CHWI mission is to address social determinants of health to increase the wellbeing of New Mexicans and improve health equity through a framework of racial equality and cultural inclusivity to best reach the marginalized and underserved in our community. To achieve this mission, we collaborate through a network of projects and community-based organizations who assist in providing direct services for improving behavioral health, health equity, and access to healthcare and resources. Led by Pathways, CHWI has successfully mobilized established Community Health Workers (CHWs) to support and enroll eligible individuals into ERAP. Ended 6/30/23
• Health Literacy - The Albuquerque COVID-19 Health Literacy Project (AHLP) is collaborative effort of the City of Albuquerque (CABQ) and the University of New Mexico (UNM), along with thirteen partner organizations across the Albuquerque area, to increase health equity through increasing COVID-19 health Literacy. Using a health promotion model based on Community Health Workers (CHWs) from communities historically disenfranchised and underserved, AHLP focuses on providing COVID-19 education, vaccine information, and health literacy in those communities. Project partners work together to provide opportunities for collaboration, networking, and support between CHWs and partner organizations, and with UNM and CABQ. AHLP has introduced health literacy tools and techniques to CHWs' ability to meaningfully communicate urgent, complex health information. AHLP has provided skill building and training on the use of health literacy and health promotion tools such as Teach Back, Motivational Interviewing, Health Coaching, Social Literacy, and Community-Based Participatory Research (CBPR). With these tools and skills, our partner organizations and CHWs are working together to host events and create outreach opportunities. Through this work, we are building and strengthening the connections between our partners and improving health equity in the City of Albuquerque. Ended 6/30/23